OB-GYN residents in programs dominated by faith-based hospitals are not receiving full reproductive health-care training, especially when it comes to abortion and postpartum sterilization, a new study published in the American Journal of Obstetrics and Gynecology found.

The researchers found that in approximately 11 percent of OB-GYN residency programs, residents spend at least 70 percent of their time in faith-based hospitals that restrict family planning services on religious grounds. Catholic hospitals, in particular, have drawn scrutiny in recent years as they have grown to encompass at least 1 in 6 acute-care hospital beds nationwide. These facilities follow directives written by the Catholic bishops that ban abortion, sterilization, and most forms of contraception.

Among the faith-based programs that responded to the survey, nearly half failed to comply with the requirement set by the Accreditation Council for Graduate Medical Education (ACGME) in 1996 to provide routine, opt-out training for abortion. In the Catholic programs, specifically, about one-fourth reported that not all of their residents meet the minimum requirement of completing 20 dilation and curettages (D and Cs), a procedure used for abortion and miscarriage management.

“It’s important to note the minimum numbers are just minimum—what an individual resident needs for competency can often be more than the minimum number,” Maryam Guiahi, associate professor of OB-GYN at the University of Colorado School of Medicine who co-wrote the report, told Rewire.News. “These residents may go out and not be well-trained even in miscarriage management.”

Training for second-trimester miscarriages and abortion was particularly lacking, with 63 percent of Catholic programs reporting inadequate training in such procedures in the operating room, and 68 percent reporting inadequate training in the outpatient setting.

“These are procedures that could be done for intrauterine fetal demises, which are basically miscarriages in the second trimester, and are often indicated in the case of a life-threatening abortion where a woman comes in septic, infected, and needs a procedure to get her healthy again,” Guiahi said.

While the researchers found that both Catholic and non-Catholic faith-based institutions restricted abortion care, the non-Catholic institutions did not appear to have the same restrictions as Catholic facilities on contraception or sterilization, Guiahi said. When it came to sterilization procedures, Guiahi said a major concern that emerged in the survey is the lack of training at Catholic institutions in tubal ligations following vaginal deliveries, which is a more skilled procedure than performing a tubal ligation after a cesarean section. More than half of Catholic programs reported inadequate training in postpartum tubal ligations after vaginal deliveries; no other faith-based programs reported a similar deficiency.

A lack of such training can hinder residents throughout their careers, Guiahi found in a 2017 study on the subject. She interviewed doctors who had to rely on colleagues to train and guide them through procedures they hadn’t learned to perform in residency. Some simply didn’t offer these services because they were so embarrassed about their lack of training.

All the programs surveyed in Guiahi’s most recent study said they provided adequate training in contraception, with about half of Catholic programs relying on off-site locations for such training. “Although contraceptive training overall is pretty adequate, we do see some deficiencies with respect to methods that the Church consider are abortifacients,” Guiahi said, pointing to copper intrauterine devices (IUDs) and emergency contraception as examples. Both forms of contraception prevent pregnancy, “and therefore are not abortifacients,” as the American College of Obstetricians and Gynecologists has noted.

Guiahi said the study provides an unusual window into practices at Catholic health-care institutions, which are often unwilling to allow such research.

She said the residency directors at the 25 programs that participated in the survey seemed to want to provide comprehensive reproductive health-care training, with 100 percent saying it was important to comply with the ACGME. But more than a third of Catholic programs reported a prior citation by the residency review committee charged with enforcing training requirements. Perhaps surprisingly, Guiahi said the residency directors often felt these citations helped by giving them leverage to improve training in the face of institutional religious barriers.